UNDERSTANDING ED ATTENDANCES IN LANARKSHIRE

1. UNDERSTANDINGED ATTENDANCESIN LANARKSHIRE Dr Veronica Devlin Lean Leader NHS Lanarkshire Prof Graham Watt Department of General Practice Glasgow University

3. population 556,000 • 3 ED’s • 194,000 new attendances in2008/09 • 10% of ED attendances are GP referrals • Population over 65 close to Scottish average

4. Bed complement • •Monklands Hospital -478 inpatient beds • •Hairmyres Hospital-353 inpatient beds • •Wishaw Hospital -633 inpatient beds

5. A Day in the Life of Monklands

6. CONTEXT • Mostly urban • Set in centre of Airdrie • High deprivation • High number of single handed GP’s • Average 66,500 new attendances per year

7. Methodology • ED records pulled for 24 hours – Tuesday • Examined by EA Programme Manager and LTC manager or Charge Nurse from ED • Categorised into broad groupings

8. Attendance Profile • 165 new attendances Admissions • 12 surgical 2 diverted from Wishaw • 5 ortho including 2#NOF • 33 medical • 1 psychiatry • 1 ITU • 1 Unknown disposition

9. 9 chest pain 8 chest infection or SOB 2 alcohol intoxication 1 accidental o/d 1 respiratory failure 1 intentional o/d 1 seizure 1 alcohol withdrawal 1 asthma 1 rash 1 palliative care 1 collapse 1 haematemesis 1 headache 1 pneumonia 1 off legs 1 respiratory failure 1 unclear! Medical

10. “Primary Care” Appropriate • 55 Primary Care appropriate • 3 referred by NHS 24 • 1 by police • 1 by GP receptionist- 4/12 old foot inj • 1 by GP - reflux • 1 by ED for detox team • 4 dialled 999 • 10 children, 5 of those in working hours

11. Long Term Conditions • 9 with at least 1 LTC • 2 known to be on SPARRA register • 1 with leg pain self referred, 999, known OA 10.00, discharged • 4 admitted with exac COPD • 1 admitted with accidental OD • 1 incidental head injury • 1 ? CVA in patient with COPD and IHD • 1 with known IHD admitted with chest pain

12. Alcohol and Drugs • 18 presentations where alcohol was involved – >10% of presentations • 6 presentations where drug use mentioned • 1 heroin o/d signed IRD

13. Nursing Home • 23 nursing homes in catchment • Average 2 admissions from NH per day • 1 documented care home admission

14. GP OOH • 10 patients diverted to GP OOH at triage • 2 were 999 self referrals • 1 abdo pain • 1 chest pain • 2 earaches • 1 sick baby • 2x20 year olds short of breath • 2 back pains • 1 unwell 43 year old

15. GP APPROPRIATE TIME OF ARRIVAL

16. Also of note… • 1 cardiac arrest who died • 1 multiple trauma who breached • 1 standby for respiratory failure who was admitted • 18 alcohol related attendances • 5 drug related attendances

17. Prospective Audit of “Elsewhere appropriate attendances”at the ED • Prospective clinician collected subjective data for month of June • Acute injuries excluded – musculoskeletal pain non-trauma included • Hairmyres 32 useable audit forms • Monklands 90 • Wishaw 121

18. Condition • Age and gender distribution • Time of registration • Referral Source • Symptom Duration • Outcome

19. Monklands by Conditionn=90

20. Monklands Gender Split

21. Monklands Age Spread

22. Monklands Attendance Spread

23. Monklands Referral Source

24. Monklands Duration of Symptoms

25. Monklands Outcome

26. NHS Lanarkshire overview

27. One of the highest 999 ambulance call to ED attendance conversion rates in Scotland • 82% versus 72%

28. 125 999 DNW’S every month

29. There is a 3 fold variance in GP practice A&E emergency referral rates - from the highest to lowest referring practices - this is consistent over the last 4 years

30. Rates have been growing year on year over the last 4 years • mean rates per 1,000 population - growing as follows • 264 to 279 to 292 and to 302 in 2008/09 • +6%, +5% and +3% respectively in each year

31. Standardised emergency admission rates • NHSL is consistently higher than the Scottish average over the last 6 years - although the gap is narrowing in recent years

32. There is a 200% variance in GP practice emergency admission rates - from the highest to lowest referring practices in 2007/08

33. There is a 100% variance in GP practice OOH contact (call) rates - from the highest to lowest referring practices in 2007/08

34. Emergency admissions in context - they account for 75% of all acute admissions and 83% of all acute bed days. • 65% of all direct emergency GP referrals to the A&E Department are admitted (49% medical and 16% surgical)

35. Demand has increased by 9% or circa 16,000 new attendances over the last 3 years.

37. 98 GP Practices • Cover paper for each Practice • Information Pack 1 - A&E attendances • Information Pack 2 - Emergency admissions

43. GP Information Pack 1 - A&E Presentations • GP Practice profile 1 - demography & deprivation • GP Practice profile 2 - Age & deprivation • GP Practice - QOF prevalence benchmarking • GP Practice benchmarking • GP Practice ranking • GP Practice referral source & flow group • Charts comparing trends over time

44. GP Information Pack 1 -Emergency Admissions • 6 year trends - “Navigator” generated • Admission numbers and rates • Bed day numbers & rates • Elective shown for completeness • CHI population change • Each GP Practice benchmarked against: • NHS Lanarkshire • NHS Scotland • North CHP • South CHP